Medication errors are increasingly recognized as an important cause of preventable deaths and injuries. A significant percentage of medication errors occur when a prescribed medication is confused with a non-prescribed medication and the non-prescribed medication is dispensed to the patient. Medication brand names can look like other brand names when handwritten or may be mistaken for another drug when ordered orally. Generic medication names can resemble other generic medication names or even brand names. Medication errors can also occur when the labeling or packaging of multiple drugs is too similar. Medication errors resulting from such confusion between drugs are often referred to as look-alike sound-alike (“LASA”) medication errors.
Millions of dollars may be spent establishing a brand name well before a drug is ever introduced to the market. Thus, drug manufacturers are extremely reluctant to change medication brand names. Changing a generic drug name can also be a complicated and expensive undertaking. Such a modification would affect all the companies that manufacture the compound, not to mention the numerous text references and software programs that refer to the generic drug name. Generic drug names may be based on word stems related to particular drug class, a factor that causes much overlap between generic drug names.
Given the resistance to change a medication name, efforts have been made to anticipate and avoid LASA medication errors before a medication name is adopted. As one example, special software has been developed to screen proposed medication names against databases of existing medication names. The software computes a numerical similarity score between the proposed drug name and other drug names. The proposed drug name is measured for its resemblance to all of the drug names stored in a massive database of medication brand and generic names.
Even with pre-screening techniques, LASA errors continue to occur. Short of a medication name change, alert systems are used to alert pharmacists of potential LASA errors. Such systems generate a warning message any time a drug product having a drug name that is included in a LASA drug pair is detected in a prescription transaction. The term “LASA drug pair,” as used herein, refers to two or more drug names that are known to be confused with each other. Each member of a LASA drug pair can be referred to as a LASA alternative drug name to the other member(s). Systems that generate warning messages any time a drug product having a drug name that is included in a LASA drug pair is detected can generate a high volume of messages, the majority of which are “false positives.” As a result, such warning messages tend to be more of a burden to busy pharmacists than an aide.
It is clear that existing pharmacy decision support and practice management systems do not adequately protect against LASA medication errors. What is needed is a system and method for intelligently detecting LASA medication errors based on more than simply whether a drug name is included in a LASA drug pair. The sensitivity of such a system and method should be adjustable, so as to provide the ability to increase or decrease the rate of LASA medication error messaging. There is further a need for a system and method that monitors prescription transactions for possible LASA medication errors and generates messages when there is a likelihood that a different medication, dispense quantity, or days supply is more appropriate.